Improving Analgesia: Farewell to Pethidine

A Multi-centre DUE Project

Susie Welch B.Pharm

Project Officer, NSW TAG

ED Pharmacist, St Vincent’s Hospital, Sydney

Coordinated by NSW Therapeutic Assessment Group

Supported by the National Institute of Clinical Studies Australia's national agency for closing the gaps between evidence and practice in health care.

Background

Is there a problem?

Prescribing of pethidine in general practice Prescribing audit in hospitals 2001 Influence of hospital prescribers Continuity of care

The Problem

• Pethidine limitations include: – higher potential for adverse effects and

interactions than other opioids– no proven advantage

• Widely prescribed in hospital despite lack of evidence

ADRAC reaction reports

DrugYears of data

collection

Number of reactions reported

to ADRAC

Sole suspected agent

Pethidine 1972-2003 2321 845Morphine 1974-2003 799 380Tramadol 1999-2003 1307 838

Evidence-based Guidelines:Evidence-based Guidelines:

Pethidine is not the strong analgesic of choice in Emergency Departments

Aim

• To increase awareness of limitations of pethidine

• To encourage use of appropriate alternatives

Approach

• Linking Emergency Department (ED) teams and pharmacists

• Work together using DUE to achieve aims

• Utilise the resources and experience available through the TAG network

The DUE Cycle

NSW TAG = NSW Therapeutic Assessment Group

• NSW TAG = independent, non-profit organisation

• Promotes quality use of medicines through collaboration and consensus.

• NSW TAG committee = representatives from teaching hospital Drug Committees in NSW and University Departments of Clinical Pharmacology.

• The TAG network represents 46 NSW public hospitals

23 Participating HospitalsAuburn Hospital Murwillumbah Hospital

Bankstown Hospital Prince of Wales Hospital

Blacktown Hospital Royal North Shore Hospital

Mt Druitt Hospital Royal Prince Alfred Hospital

Grafton Base Hospital Southern AHS (7 hospitals)

Frankston Hospital (Vic) Sydney / Sydney Eye Hospital

John Hunter Hospital Westmead Hospital

Lismore Base Hospital Wollongong Hospital

Mullumbimby Hospital

Approach

• DUE – 3 cycles over 12 months, commenced in September 2002

– Each cycle involved 1 week audit of ED prescriptions for pethidine.

– Audit results fed back to prescribers

– Audit results directed education and messages specific to local ED practice

Clinical Reference Committee

Prof Ric Day Prof Ric Day - Clinical Pharmacologist, SVH / - Clinical Pharmacologist, SVH / NSWTAGNSWTAGDr Andis Graudins Dr Andis Graudins - Emergency Physician, Prince of Wales- Emergency Physician, Prince of WalesA/Prof Milton Cohen A/Prof Milton Cohen - Pain Physician, Darlinghurst Pain Clinic - Pain Physician, Darlinghurst Pain Clinic Dr Alex WodakDr Alex Wodak - Alcohol and Drug Specialist SVH- Alcohol and Drug Specialist SVHDr Robert Dowsett Dr Robert Dowsett - Emergency Physician, Westmead- Emergency Physician, WestmeadMs Kanan Gandecha Ms Kanan Gandecha - Pharmaceutical Services, NSW Health- Pharmaceutical Services, NSW HealthMs Margaret KnightMs Margaret Knight - Consumer- ConsumerMr Stuart DorkinMr Stuart Dorkin - ED Nurse, Westmead Hospital- ED Nurse, Westmead HospitalMs Kathleen RyanMs Kathleen Ryan - Quality Manager, St Vincents Hospital- Quality Manager, St Vincents HospitalMs Nolene SmithMs Nolene Smith - Project Officer, NICS- Project Officer, NICSMs Susie WelchMs Susie Welch - ED Pharmacist, Project Officer, NSW TAG- ED Pharmacist, Project Officer, NSW TAGMs Karen KayeMs Karen Kaye - Executive Officer, NSW TAG- Executive Officer, NSW TAG

NSW TAG’s Role as Facilitator

• Hospital Coordinators– SUPPORT them in their liaison with ED staff & hospital

committees

– PROVIDE materials to facilitate data collection, education and feedback

– FACILITATE collaboration and sharing of experience to help spread practice improvement

– COMMUNICATION strategies - email, monthly teleconference, website (www.nswtag.org.au )

NSW TAG’s Role as Facilitator

• Coordinate evaluation of project progress.

– Data on volume of parenteral analgesics issued from pharmacy departments each month

Strategies - Audit/ Feedback Process

• Cycle 1– Focus on educational messages

– Alternative treatment guidelines

posters

bookmarks

Audit/ Feedback Process• Cycle 2

– Ongoing areas of concern• morphine allergy

• colic

Answers to Frequently Asked Questions

• patients seeking pethidine,

• feedback from consumer rep

Patient Waiting Room Poster

Have We Made a Difference ?

Use of pethidine in EDs: Indications identified to date

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Pethidine Issues to EDsAll hospitals

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Total issues of Morphine to ED by Peer Grouping

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Total issues of tramadol to EDs All hospitals

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What’s Next ?

Conclusion• A clear reduction in ED use of pethidine has

occurred.

More importantly:• Prescribers are thinking about

• alternatives • most appropriate analgesia

• Promotion of information sharing between pharmacists, nurses and doctors and ED staff enable prescribers to make appropriate treatment

choices

Hospital Coordinators

Ms Wai-Jen Lee

Ms Charissa Salzmann

Ms Margaret Macarthur

Ms Helen Evans

Ms Paula Doherty

Ms Jenni Prince

Ms Linda Graudins

Ms Roseleen O’Doherty

Ms Vanessa Simpson

Ms Gabrielle Couch

Ms Cathy Vlouhos

Ms Lorraine Koller

Dr Rob Dowsett

Mr Lou Gaetani

Ms Mary Mitchelhill